<?php
$inputWidthPixel = "190px";
$inputWidth = 180;
?>
<div class="midden_container">
	<table width="100%" height=506 border="0" cellpadding="5" cellspacing="5">
		<tr>
			<td width="51%" rowspan="2" align="center" valign="middle"> 
				<iframe id="youtubeMovieHome" width="425" height="349" src="http://www.youtube.com/embed/2CBCfbQ1Yxk" frameborder="0" allowfullscreen="1" ></iframe>
			</td>
			<td width="49%" height="59" align="left" valign="top"><h1><strong>Registreren</strong></h1>
				<h1><img src="images/spacer.png" width="384" height="1" /></h1>
			</td>
		</tr>
		<tr>
			<td valign="top">
				<form name="registerForm" onsubmit="javascript: return checkForm(this);" >
				<table width="536" height="279" cellpadding="0" cellspacing="0">
					<tr>
						<td width="163">
							<table width="536" height="279" cellpadding="0" cellspacing="0">
								<tr>
									<td width="163">
										Contactpersoon*:
									</td>
									<td>
										<!-- onblur="javascript: checkRequiredInput(this.id, false);" -->
										<input type=text id="Contact" style="width:<?= $inputWidthPixel; ?>" />
									</td>
				                </tr>
				                <tr>
									<td>
										Functie:
									</td>
									<td>
										<input id="function" type="text" style="width:<?= $inputWidthPixel; ?>" />
									</td>
								</tr>
				                <tr>
									<td>
										Email*: (tevens de login)
									</td>
									<td>
										<input type="email" id="email"  style="width:<?= $inputWidthPixel; ?>" />
									</td>
				                </tr>
				                <tr>
									<td>
										Email*: (bevestiging)
									</td>
									<td>
										<input type="email" id="email2" style="width:<?= $inputWidthPixel; ?>" />
									</td>
				                </tr>
				                <tr><td height="10px" colspan="2"></td></tr>
				                <tr>
									<td>
										Bedrijfsnaam*:
									</td>
				                  	<td>
				                  		<input type="text" id="name" style="width:<?= $inputWidthPixel; ?>" />
				                  	</td>
				                </tr>
				                <tr>
				                  	<td>
				                  		Adres*:
				                  	</td>
				                  	<td>
				                  		<input type="text" id="address" style="width:<?= $inputWidthPixel; ?>" />
				                  	</td>
				                </tr>
				                <tr>
									<td>
										Postcode*:
									</td>
				                  	<td>
										<input type="text" id="Zipcode" style="width:<?= ($inputWidth/3); ?>px" />
									</td>
				                </tr>
				                <tr>
									<td>
										Plaats*:
									</td>
				                  	<td>
										<input type="text" id="City" style="width:<?= $inputWidthPixel; ?>px" />
									</td>
				                </tr>
				                <tr>
				                  	<td>
				                  		Land*:
				                  	</td>
				                  	<td>
				                  		<select id="land" name="CountryID">
						                    <option value="Afghanistan">Afghanistan</option>
						                    <option value="Albania">Albania</option>
						                    <option value="Algeria">Algeria</option>
						                    <option value="American Samoa">American Samoa</option>
						                    <option value="Andorra">Andorra</option>
						                    <option value="Angola">Angola</option>
						                    <option value="Anguilla">Anguilla</option>
						                    <option value="Antarctica">Antarctica</option>
						                    <option value="Antigua and Barbuda">Antigua and Barbuda</option>
						                    <option value="Argentina">Argentina</option>
						                    <option value="Armenia">Armenia</option>
						                    <option value="Aruba">Aruba</option>
						                    <option value="Australia">Australia</option>
						                    <option value="Austria">Austria</option>
						                    <option value="Azerbaijan">Azerbaijan</option>
						                    <option value="Bahamas">Bahamas</option>
						                    <option value="Bahrain">Bahrain</option>
						                    <option value="Bangladesh">Bangladesh</option>
						                    <option value="Barbados">Barbados</option>
						                    <option value="Belarus">Belarus</option>
						                    <option value="Belgium">Belgium</option>
						                    <option value="Belize">Belize</option>
						                    <option value="Benin">Benin</option>
						                    <option value="Bermuda">Bermuda</option>
						                    <option value="Bhutan">Bhutan</option>
						                    <option value="Bolivia">Bolivia</option>
						                    <option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
						                    <option value="Botswana">Botswana</option>
						                    <option value="Bouvet Island">Bouvet Island</option>
						                    <option value="Brazil">Brazil</option>
						                    <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
						                    <option value="British Virgin Islands">British Virgin Islands</option>
						                    <option value="Brunei">Brunei</option>
						                    <option value="Bulgaria">Bulgaria</option>
						                    <option value="Burkina Faso">Burkina Faso</option>
						                    <option value="Burundi">Burundi</option>
						                    <option value="Cambodia">Cambodia</option>
						                    <option value="Cameroon">Cameroon</option>
						                    <option value="Canada">Canada</option>
						                    <option value="Cape Verde">Cape Verde</option>
						                    <option value="Cayman Islands">Cayman Islands</option>
						                    <option value="Central African Republic">Central African Republic</option>
						                    <option value="Chad">Chad</option>
						                    <option value="Chile">Chile</option>
						                    <option value="China">China</option>
						                    <option value="Christmas Island">Christmas Island</option>
						                    <option value="Cocos Islands">Cocos Islands</option>
						                    <option value="Colombia">Colombia</option>
						                    <option value="Comoros">Comoros</option>
						                    <option value="Congo">Congo</option>
						                    <option value="Cook Islands">Cook Islands</option>
						                    <option value="Costa Rica">Costa Rica</option>
						                    <option value="Croatia">Croatia</option>
						                    <option value="Cuba">Cuba</option>
						                    <option value="Cyprus">Cyprus</option>
						                    <option value="Czech Republic">Czech Republic</option>
						                    <option value="Denmark">Denmark</option>
						                    <option value="Djibouti">Djibouti</option>
						                    <option value="Dominica">Dominica</option>
						                    <option value="Dominican Republi">Dominican Republic</option>
						                    <option value="East Timor">East Timor</option>
						                    <option value="Ecuador">Ecuador</option>
						                    <option value="Egypt">Egypt</option>
						                    <option value="El Salvador">El Salvador</option>
						                    <option value="Equatorial Guinea">Equatorial Guinea</option>
						                    <option value="Eritrea">Eritrea</option>
						                    <option value="Estonia">Estonia</option>
						                    <option value="Ethiopia">Ethiopia</option>
						                    <option value="Falkland Islands">Falkland Islands</option>
						                    <option value="Faroe Islands">Faroe Islands</option>
						                    <option value="Fiji">Fiji</option>
						                    <option value="Finland">Finland</option>
						                    <option value="Franc">France</option>
						                    <option value="French Guiana">French Guiana</option>
						                    <option value="rench Polynesia">French Polynesia</option>
						                    <option value="French Southern Territories">French Southern Territories</option>
						                    <option value="Gabon">Gabon</option>
						                    <option value="Gambia">Gambia</option>
						                    <option value="Georgia">Georgia</option>
						                    <option value="Germany">Germany</option>
						                    <option value="Ghana">Ghana</option>
						                    <option value="Gibraltar">Gibraltar</option>
						                    <option value="Greece">Greece</option>
						                    <option value="Greenland">Greenland</option>
						                    <option value="Grenada">Grenada</option>
						                    <option value="Guadeloupe">Guadeloupe</option>
						                    <option value="Guam">Guam</option>
						                    <option value="Guatemala">Guatemala</option>
						                    <option value="Guinea">Guinea</option>
						                    <option value="Guinea-Bissa">Guinea-Bissau</option>
						                    <option value="Guyana">Guyana</option>
						                    <option value="Haiti">Haiti</option>
						                    <option value="Heard and McDonald Is.">Heard and McDonald Is.</option>
						                    <option value="Honduras">Honduras</option>
						                    <option value="Hong Kong">Hong Kong</option>
						                    <option value="Hungary">Hungary</option>
						                    <option value="Iceland">Iceland</option>
						                    <option value="India">India</option>
						                    <option value="Indonesia">Indonesia</option>
						                    <option value="Iran">Iran</option>
						                    <option value="Iraq">Iraq</option>
						                    <option value="Ireland">Ireland</option>
						                    <option value="Israel">Israel</option>
						                    <option value="Italy">Italy</option>
						                    <option value="Ivory Coast">Ivory Coast</option>
						                    <option value="Jamaica">Jamaica</option>
						                    <option value="Japan">Japan</option>
						                    <option value="Jordan">Jordan</option>
						                    <option value="Kazakhstan">Kazakhstan</option>
						                    <option value="Kenya">Kenya</option>
						                    <option value="Kiribati">Kiribati</option>
						                    <option value="Korea, North">Korea, North</option>
						                    <option value="Korea, South">Korea, South</option>
						                    <option value="Kuwait">Kuwait</option>
						                    <option value="Kyrgyzstan">Kyrgyzstan</option>
						                    <option value="Laos">Laos</option>
						                    <option value="Latvia">Latvia</option>
						                    <option value="Lebanon">Lebanon</option>
						                    <option value="Lesotho">Lesotho</option>
						                    <option value="Liberia">Liberia</option>
						                    <option value="Libya">Libya</option>
						                    <option value="Liechtenstein">Liechtenstein</option>
						                    <option value="Lithuania">Lithuania</option>
						                    <option value="Luxembourg">Luxembourg</option>
						                    <option value="Macau">Macau</option>
						                    <option value="Macedonia">Macedonia</option>
						                    <option value="Madagascar">Madagascar</option>
						                    <option value="Malawi">Malawi</option>
						                    <option value="Malaysia">Malaysia</option>
						                    <option value="Maldives">Maldives</option>
						                    <option value="Mali">Mali</option>
						                    <option value="Malta">Malta</option>
						                    <option value="Marshall Islands">Marshall Islands</option>
						                    <option value="Martinique">Martinique</option>
						                    <option value="Mauritania">Mauritania</option>
						                    <option value="Mauritius">Mauritius</option>
						                    <option value="Mayotte">Mayotte</option>
						                    <option value="Mexico">Mexico</option>
						                    <option value="Micronesia">Micronesia</option>
						                    <option value="Moldova">Moldova</option>
						                    <option value="Monaco">Monaco</option>
						                    <option value="Mongolia">Mongolia</option>
						                    <option value="Montserrat">Montserrat</option>
						                    <option value="Morocco">Morocco</option>
						                    <option value="Mozambique">Mozambique</option>
						                    <option value="Myanmar">Myanmar</option>
						                    <option value="Namibia">Namibia</option>
						                    <option value="Nauru">Nauru</option>
						                    <option value="Nepal">Nepal</option>
						                    <option value="Nederland" selected="selected">Nederland</option>
						                    <option value="Netherlands Antilles">Netherlands Antilles</option>
						                    <option value="New Caledonia">New Caledonia</option>
						                    <option value="New Zealand">New Zealand</option>
						                    <option value="Nicaragua">Nicaragua</option>
						                    <option value="Niger">Niger</option>
						                    <option value="Nigeria">Nigeria</option>
						                    <option value="Niue">Niue</option>
						                    <option value="Norfolk Island">Norfolk Island</option>
						                    <option value="Northern Mariana Is.">Northern Mariana Is.</option>
						                    <option value="Norway">Norway</option>
						                    <option value="Oman">Oman</option>
						                    <option value="Pakistan">Pakistan</option>
						                    <option value="Palau">Palau</option>
						                    <option value="Panama">Panama</option>
						                    <option value="Papua New Guinea">Papua New Guinea</option>
						                    <option value="Paraguay">Paraguay</option>
						                    <option value="Peru">Peru</option>
						                    <option value="Philippines">Philippines</option>
						                    <option value="Pitcairn Island">Pitcairn Island</option>
						                    <option value="Poland">Poland</option>
						                    <option value="Portugal">Portugal</option>
						                    <option value="Puerto Rico">Puerto Rico</option>
						                    <option value="Qatar">Qatar</option>
						                    <option value="Reunion">Reunion</option>
						                    <option value="Romania">Romania</option>
						                    <option value="Russia">Russia</option>
						                    <option value="Rwanda">Rwanda</option>
						                    <option value="Saint Kitts &amp; Nevis">Saint Kitts &amp; Nevis</option>
						                    <option value="Saint Lucia">Saint Lucia</option>
						                    <option value="Saint Vincent &amp; Grenadines">Saint Vincent &amp; Grenadines</option>
						                    <option value="Samoa">Samoa</option>
						                    <option value="San Marino">San Marino</option>
						                    <option value="Sandwich Is.">Sandwich Is.</option>
						                    <option value="Sao Tome and Principe">Sao Tome and Principe</option>
						                    <option value="Saudi Arabia">Saudi Arabia</option>
						                    <option value="Senegal">Senegal</option>
						                    <option value="Seychelles">Seychelles</option>
						                    <option value="Sierra Leone">Sierra Leone</option>
						                    <option value="Singapore">Singapore</option>
						                    <option value="Slovakia">Slovakia</option>
						                    <option value="Slovenia">Slovenia</option>
						                    <option value="Somalia">Somalia</option>
						                    <option value="South Africa">South Africa</option>
						                    <option value="Spain">Spain</option>
						                    <option value="Sri Lanka">Sri Lanka</option>
						                    <option value="St. Helena">St. Helena</option>
						                    <option value="St. Pierre and Miquelon">St. Pierre and Miquelon</option>
						                    <option value="Sudan">Sudan</option>
						                    <option value="Suriname">Suriname</option>
						                    <option value="Swaziland">Swaziland</option>
						                    <option value="Sweden">Sweden</option>
						                    <option value="Switzerland">Switzerland</option>
						                    <option value="Syria">Syria</option>
						                    <option value="Taiwan">Taiwan</option>
						                    <option value="Tajikistan">Tajikistan</option>
						                    <option value="Tanzania">Tanzania</option>
						                    <option value="Thailand">Thailand</option>
						                    <option value="Togo">Togo</option>
						                    <option value="Tokelau">Tokelau</option>
						                    <option value="Tonga">Tonga</option>
						                    <option value="Trinidad and Tobago">Trinidad and Tobago</option>
						                    <option value="Tunisia">Tunisia</option>
						                    <option value="Turkey">Turkey</option>
						                    <option value="Turkmenistan">Turkmenistan</option>
						                    <option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
						                    <option value="Tuvalu">Tuvalu</option>
						                    <option value="U.S. Minor Outlying Islands">U.S. Minor Outlying  Islands</option>
						                    <option value="Uganda">Uganda</option>
						                    <option value="Ukraine">Ukraine</option>
						                    <option value="United Arab Emirates">United Arab Emirates</option>
						                    <option value="United Kingdom">United Kingdom</option>
						                    <option value="United States">United States</option>
						                    <option value="Uruguay">Uruguay</option>
						                    <option value="Uzbekistan">Uzbekistan</option>
						                    <option value="Vanuatu">Vanuatu</option>
						                    <option value="Vatican City">Vatican City</option>
						                    <option value="Venezuela">Venezuela</option>
						                    <option value="Vietnam">Vietnam</option>
						                    <option value="Virgin Islands">Virgin Islands</option>
						                    <option value="Wallis and Futuna Islands">Wallis and Futuna Islands</option>
						                    <option value="Western Sahara">Western Sahara</option>
						                    <option value="Yemen">Yemen</option>
						                    <option value="Yugoslavia (Former)">Yugoslavia (Former)</option>
						                    <option value="Zaire">Zaire</option>
						                    <option value="Zambia">Zambia</option>
						                    <option value="Zimbabwe">Zimbabwe</option>
										</select>
									</td>
				                </tr>
				                <tr><td height="10px" colspan="2"></td></tr>
				                <tr>
				                  	<td>
				                  		Wachtwoord*
				                  	</td>
				                  	<td>
				                  		<input type="password" id="password" name="password" style="width:<?= $inputWidthPixel; ?>" />
				                  	</td>
				                </tr>
				                <tr>
									<td>
										Wachtwoordbevestiging*
									</td>
									<td>
										<input type="password" id="passwordconfirm" name="passwordconfirm" style="width:<?= $inputWidthPixel; ?>" />
									</td>
				                </tr>
				                <tr><td height="10px" colspan="2"></td></tr>
				                <tr>
									<td colspan="2" align="center">
										<input type="submit" value="Aanmelden" />
				                    	<!-- <input type="button" onClick="javascript: registerAsShop();" value="Aanmelden" /> -->
				                	</td>
				            	</tr>
				        	</table>
						</td>
					</tr>
				</table>
				</form>
				<br /><br />
				<p><img src="images/spacer.png" alt="" width="384" height="1" /></p>
				<p>Na de registratie kun je aan slag om je webshop(s) aan te melden</p><br>
				<p>Affiliate Marketing is niet toegestaan via prijsgezocht</p>
			</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
	</table>
</div>